The VHA is engaged in a major initiative to implement recommendations from the President's New Freedom Commission for the care of persons with mental illness and substance use disorders. The Secretary's Mental Health Strategic Plan lays out goals to create a system of care that is recovery-oriented, high quality, and delivers evidenced-based practices (EBP). The minimal participation of caregivers in VA clinical care of persons with Severe Mental Illness (SMI) constitutes a large gap between what we know work ("evidence") and what we do ("practice"). This study tested an intervention to help close this gap. Previous research consistently demonstrates that individuals with SMI have improved outcomes when families are active participants in their care, including treatment retention, participation in vocational services, and empowerment. Controlled trials show that when families participate in family psychoeducation (FPE), relapse rates are cut in half and clinical symptoms improve. A national VA survey indicated that 0% offer FPE programs conforming to EBP guidelines. This proposal thus tested a veteran-centered program designed to enhance family/caregiver involvement in the veteran's mental health care with a strategy that promotes the veteran's recovery.
We tested the effectiveness of an innovative, structured, brief and manualized family engagement intervention for veterans with SMI, Family Member Provider Outreach (FMPO). FMPO aims to empower and educate veterans to increase the likelihood that the veteran's family/caregiver will become constructive partners in their mental health care. In the FMPO model's first "patient phase," a trained outreach person (a Family Member Provider (FMP), who has a relative with a serious psychiatric illness, works with the veteran to help resolve veteran-based barriers to family involvement, to empower veteran-consumers to encourage and facilitate family involvement and to encourage their mental health providers to involve their families. The second "family phase" of FMPO occurred with the veteran's and family's permission. Here, the FMP engaged in education and support with relatives to strengthen their ability to support the veteran and to interact effectively with the veteran's regular treatment team. We tested the following primary aims based on Donabedian's Framework: Processes of Care: (1) to evaluate the effect relative to enhanced Treatment as usual (e-TAU) of FMPO on family involvement in care; Outcomes of Care: (2) to evaluate the effect (relative to e-TAU) of FMPO on veteran outcomes. Secondary aims will (3) estimate the direct cost per patient of providing FMPO, relative to e-TAU; (4) evaluate the effect (relative to e-TAU) of FMPO on family member outcomes. We also investigated how the FMPO program works with these aims: (6) to evaluate the utility of the family component of FMPO; and (7) to assess the acceptability of FMPO and barriers and facilitators of its implementation.
We conducted a prospective randomized experimental trial comparing veterans assigned to FMPO (n=117) or e-TAU (n=115). Veterans recruited from Baltimore and Perry Point (N=200) and West LA VAMC clinics (N=32) and family member participants completed baseline and 6-month post-baseline assessments. Follow up rates were (178/215; 83%). Self report (symptoms, family functioning) and chart review (family participation in care, service utilization) provided study data. Veterans (18-75 years) had a psychotic disorder diagnosis, at least two outpatient visits and contact with a family member/caregiver over the last 6 months. Family members (18-80 years) were enrolled with veteran permission. FMPO is a brief recovery-oriented model delivered by a clinician who has a family member with mental illness. The family member provider met with the consumer for 2-3 sessions and when permitted with the family for 2-3 sessions. The sessions help consumers identify preferences regarding family involvement and develop strategies to help them meet their goals. The control condition (e-TAU) provides consumers a comprehensive list of available family services. A Generalized Linear Mixed Model analytic strategy was used for primary aims focusing on 1) processes of care (proportion of patients with any clinician-family contact; numbers of clinician-family contacts) and 2) on veteran outcomes (Mental Health Recovery Meaure scores), experience of mental health treatment (satisfaction with family mental health treatment; knowledge of mental health services; barriers to involving families) and family relationships (satisfaction with family relationships; family conflict, functioning, and support).
In the sample, 84% were men and the mean age was 51.6 (SD9.1). Almost 20% were married, and 66% had children. A total of 36% were Caucasian an 56% were African American. The overall final results are still being analyzed. However, with respect to treatment participation, 85% (92/108) consumers assigned to FMPO received at least one session (M=1.8, Median and Mode=2). Fifty percent (54/108) had at least one family session (M=1.12; Median=0.5; Mode=0). Family member participants included spouse/significant other (24%), parent/step-parent (20%), child (17%), sibling (15%), other relative (11%), and friend (9%).
Increased participation of veterans with SMI in family psychoeducation and family involvement in mental health care promises to reduce symptoms, increase adherence, and improve veterans' outcomes. The FMPO model also promises to increase the veterans' empowerment and recovery. The study will be completed over the next year. To date, presentation of findings has suggested that the FMPO model is feasible. The baseline data on treatment preferences underscores the importance of reviewing options with veterans and devloping a treatment plan that honors their preferences. In addition, the fact that veterans can articulate differential benefits and concerns regarding family treatment underscores the need to specifically address these issues with patients. Analysis of study data will be able to determine if baseline preferences predict outcomes.
- Haselden M, Dixon LB, Overley A, Cohen AN, Glynn SM, Drapalski A, Piscitelli S, Thorning H. Giving Back to Families: Evidence and Predictors of Persons with Serious Mental Illness Contributing Help and Support to Families. Community mental health journal. 2018 May 1; 54(4):383-394.
- Dixon LB, Glynn SM, Cohen AN, Drapalski AL, Medoff D, Fang LJ, Potts W, Gioia D. Outcomes of a brief program, REORDER, to promote consumer recovery and family involvement in care. Psychiatric services (Washington, D.C.). 2014 Jan 1; 65(1):116-20.
- Cohen AN, Drapalski AL, Glynn SM, Medoff D, Fang LJ, Dixon LB. Preferences for family involvement in care among consumers with serious mental illness. Psychiatric services (Washington, D.C.). 2013 Mar 1; 64(3):257-63.
- Glynn SM, Dixon LB, Cohen A, Murray-Swank A. The Family Member Provider Outreach program. Psychiatric services (Washington, D.C.). 2008 Aug 1; 59(8):934.
- Cohen AN, Drapalski A, Glynn S, Medoff D, Fang L, Dixon L, Young AS. Preferences for family involvement in care by consumers with serious mental illness. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 25; Baltimore, MD.
- Dixon L, Drapalski A, Cohen AN, Glynn SM, Medoff D. The Effectiveness of Shared Decision Making for Persons with Mental Illness in Promoting Recovery and Family Involvement in Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.
- Cohen AN, Glynn SM, Drapalski A, Dixon L. Engaging Families in the Care of Veterans with SMI. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR.
Mental, Cognitive and Behavioral Disorders, Health Systems
Caregivers – not professionals, Education (patient), Schizophrenia